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Report 48 February 2014

Alexandra Bonnefoy with David Gionet-Landry

Humanitarian Telemedicine

Potential Telemedicine Applications to Assist Developing

Countries in Primary and Secondary Care

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Short title: ESPI Report 48 ISSN:2076-6688

Published in February 2014 Price: €11

Editor and publisher:

European Space Policy Institute, ESPI

Schwarzenbergplatz 6 • 1030 Vienna • Austria http://www.espi.or.at

Tel. +43 1 7181118-0; Fax -99

Rights reserved – No part of this report may be reproduced or transmitted in any form or for any purpose with- out permission from ESPI. Citations and extracts to be published by other means are subject to mentioning

“Source: ESPI Report 48; February 2014. All rights reserved” and sample transmission to ESPI before publish- ing.

ESPI is not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, product liability or otherwise) whether they may be direct or indirect, special, inciden- tal or consequential, resulting from the information contained in this publication.

Design: Panthera.cc

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Table of Contents

Preface 5

Executive Summary 6

1. Introduction 9

1.1 Technological Prowess 9

1.2 Telemedicine’s Contribution to Society 9

1.3 Telemedicine and Humanitarian Telemedicine 10

2. From Telemedicine to Humanitarian Telemedicine 11

2.1 What Is Telemedicine? 11

2.1.1 Defining Telemedicine 11

2.1.2 Terms and Terminology 12

2.1.3 Applications of Telemedicine 13

2.2 Widespread Use of Telemedicine in Industrialised Countries 14

2.2.1 International Community 14

2.2.2 National Initiatives 16

2.3 Defining Humanitarian Telemedicine 17

Part 1. Successful Humanitarian Telemedicine Projects 19

3. Popular Uses of Humanitarian Telemedicine 19

3.1 Permanent Situation of Hardship 19

3.2 Situations of Humanitarian Crisis 20

3.2.1 Primary Care 21

3.2.2 Secondary Care 22

4. Telemedicine: A Springboard for Cooperation and Development 25

4.1 Industrialised/Developing Country Cooperation 25

4.1.1 International Institutions’ Initiatives 25

4.1.2 National Initiatives 27

4.2 Cooperation between Developing Countries: The Indian Experience 28

4.2.1 Indian Telemedicine Background 28

4.2.2 Indian Inter-Country Telemedicine Initiatives 30

Part 2. The Way Forward for Developing Humanitarian Telemedicine Projects 32

5. Lessons Learned 32

5.1 Positive Impact of Humanitarian Telemedicine 32

5.2 What Works for Developing Countries 33

5.2.1 Focus on Medical Aid 33

5.2.2 Information Gathering 34

5.3 Challenges of Telemedicine in Developing Countries 35

5.3.1 Practical Considerations 35

5.3.2 General Considerations 37

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6. Considerations for Primary Care in Humanitarian Telemedicine 39

6.1 Relevance of Primary Care Humanitarian Telemedicine 39

6.1.1 Need for Primary Care 39

6.1.1 Opportunities for Primary Care Telemedicine 43

6.2 Industrialised/Developing Country Humanitarian Telemedicine Primary Care:

Considerations and Potential Way forward 45

6.2.1 General Project Considerations 45

6.2.2 Prototyping: Potential Way forward 49

7. Conclusion and Recommendations 57

7.1 Conclusion 57

7.2 Recommendations 58

List of Acronyms 59

Acknowledgements 61

About the Authors 61

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Preface

This report seeks to address new potential avenues for humanitarian telemedicine (HTM), a rapidly evolving field where the space community has a critical role to play.

HTM utilizes the tools of telemedicine to pro- vide medical services to individuals in re- mote, underserved and underprivileged ar- eas. For the purpose of this report, telemedi- cine is understood as the delivery of health care services, where distance is an obstacle, by health care professionals using informa- tion and communication technologies for the exchange of information for diagnosis, treat- ment and prevention of disease and injuries, research and evaluation, all in the interests of advancing the health of individuals and their communities.

The report first reviews the literature on telemedicine, which has developed tremen- dously in recent years. It then reviews a set

of key case studies, taking place in a range of geographical areas, that have helped push telemedicine forward. It highlights ways in which telemedicine can act as a tool to link the medical communities of different coun- tries and continents. Finally, it discusses various prototypes that could be used to test and measure the appropriateness of such projects, focusing on the potential of HTM for assisting the delivery of primary care in de- veloping countries.

The report follows a conference organized by ESPI that took place in Vienna in 2012. As a follow-up to the publication of this report, a conference on HTM will be organized by ESPI.

The conference will serve as an opportunity to discuss the content of this report, the fu- ture of HTM in general, and a potential way forward for prototyping the provision of pri- mary care HTM.

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Executive Summary

Overview

The use of technology has benefited the medical world tremendously. Through new tools, new software, and new equipment, medical opportunities have been enhanced by technology. This is most evident in the deliv- ery of remote medical care, referred to as telemedicine. Telemedicine, which has grown to include applications such as telecare, tele- surgery, and teleradiology, is intrinsically linked to technology and, in particular, the advancement of communication technologies.

The advent of satellite-enabled capabilities (telecommunication, global positioning and earth observation satellites), the Internet, and terrestrial networks, is enabling a broader healthcare reach through telemedi- cine. It has become a sought out method of administrating medical care both in industri- alised and developing countries. In the latter case, it has the potential to improve health- care for all, especially in regions where doc- tors are often scarce and where assistance from afar is the only realistic care possibility.

The discipline of telemedicine has evolved to such a point that certain countries are now integrating it into their national health poli- cies and practices. Not only is the number of programs carried out by national institutions growing, but the topic now also occupies a central place in international discussions and debates. The World Health Organization, the United Nations, the European Union, the North Atlantic Treaty Organization, and a range of other regional institutions, such as the South Asian Association for Regional Co- operation, are all increasingly involved in telehealth and telemedicine projects, initia- tives, and policymaking.

While telemedicine is widely used in industri- alised states, there is a great interest in its potential uses for developing countries, par- ticularly in the field of humanitarian aid. Hu- manitarian telemedicine (HTM), which refers to the provision of telemedicine (primary and/or secondary) to developing countries in times of immediate and/or permanent medi- cal need with the aim of improving personal health, has emerged as a fully-fledged disci- pline. It not only enables a broader reach for medical activities, but also better access to care for patients. Such humanitarian support

can be delivered from industrialised and/or developing countries and it can provide pri- mary and/or secondary care to countries in permanent need of medical aid or in immedi- ate situations of crisis. The majority of HTM projects deal with the delivery of secondary care as well as the teletraining of health pro- fessionals. Additionally, it has been used ex- tensively in disaster relief situations. Suc- cessful projects have seen aid delivered by industrialised and developing countries alike.

In industrialised countries, hospitals, national agencies, non-governmental organisations, and the military have all been involved in HTM. Many telemedicine initiatives and pro- jects have emerged in the past 15 years, making medical care easier to provide at a distance. Recent technological developments have further contributed to the advancement of telemedicine. As some of the break- throughs in telemedicine have benefited from the use of space-based facilities, the space community is keen to develop projects on this particular topic, including on HTM. Thus, the United Nations Office for Outer Space Affairs, the European Space Agency, as well as national space agencies such as CNES, DLR, NASA, and ROSCOSMOS, have all been involved in projects relating to telemedicine.

However, HTM is also provided by developing countries themselves, and none has been more active in that field than India. Both its national space agency, ISRO, and the Apollo Hospitals network have helped develop tele- medicine for domestic use. Not only has the network linked main hospitals to their rural counterparts, but it has also developed mo- bile solutions to reach a greater number of patients. Moreover, India has been actively enabling and developing the use of HTM in both South East Asia and Africa.

Telemedicine has come to be regarded as an effective way of not only delivering care, but of doing so to underserved regions. HTM im- proves access to healthcare as well as the very quality of that care. It increases the medical knowledge of doctors (on both ends of the teleconsultation) and benefits future generations through improved health. Most importantly, it saves lives. However, for telemedicine to reach its full potential, great focus must be placed on medical aspects, and on the needs at the ground level. Telemedi-

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cine may rely extensively on technology, but medical treatment should be the focus of any HTM project. In addition, all projects should undergo strict ex ante analysis (political, economic, legal, cultural, and structural,) in order to mitigate their risk levels, as high dropout rates often follow the pilot stage, and sustainability issues can arise in the medium to long term.

The need for primary care projects is vital.

Not only is there a void in this area of tele- medicine, but there is a strong need for the improvement of primary care in many parts of the developing world. The unequal distri- bution of health care workers between low- income and high-income countries, as well as the constant demand for primary health care in developing countries, constitutes a strong case for primary care HTM projects. There- fore, with the greater supply of medical pro- fessionals in industrialised states and the benefits that increased primary care could bring to developing countries, there is an opportunity to pick this low-hanging fruit and increase international medical cooperation.

Moreover, the widespread availability of technological tools, through the increased usage of mobile phones, and the increasing number of Internet users, further enable the use of HTM. Above all, HTM can be a very effective tool even with modest equipment.

However, the use of primary care HTM, espe- cially between industrialised and developing countries in permanent situations of need, has been discussed very little in the literature on telemedicine. A potential way forward in developing primary care projects is to test their viability in a context of permanent medical need. To this end, this report pro- poses three pilot project formats that could be used to test the features of primary care HTM: (1) a mobile unit, (2) a fixed remote unit, and (3) a unit alongside local healthcare facilities. As part of such pilot projects, issues such as culture, infrastructure, doctor-patient relationship, and sustainability must all be addressed. This report engages in a compara- tive analysis of all three models. The level of technology they require, their sustainability, along with the different assessment opportu- nities that they present, are addressed.

The aim of the report is to provide an over- view of telemedicine and a more in-depth analysis of HTM, while analysing successful existing projects and considering the issues that can arise when developing and sustain- ing such projects, particularly in primary care. Ultimately, this report is designed to address HTM as a field to be more broadly acknowledged. It also aims to pave the way for further discussions on the development of a pilot project in the field of primary care

HTM. Additionally, as part of a larger activity, ESPI will organize an event where HTM and these three types of pilot projects will be explored; following which, one is expected to be launched.

Recommendations

From the analysis provided in this report, lessons can be extracted and formulated for the purpose of HTM. Considering that tele- medicine is a field ripe for development, that it has proven successful in developing coun- tries, and that there is a vacuum with regards to primary care, it is recommended that:

1. Primary care HTM should be further ex- plored.

The field of HTM has mostly flourished with regards to secondary care. Primary care, which is of critical importance for patients in the rural areas of developing countries, has not witnessed the same level of innovative HTM. Therefore, test- ing the potential of such projects is a timely opportunity. Controlled evaluations are a particularly pertinent way of testing this.

2. HTM, fostered by technological advances, should continue to be utilised to improve health care for those most in need.

With the field of information and tele- communication technology developing at great speed, and the populations of many developing countries experiencing poor health outcomes, there is much potential for using ICT and space-based infrastruc- ture for solving pressing health problems in the developing world. In a number of cases, such as those enabled by VSAT in India, telemedicine initiatives whereby doctors based in urban centres adminis- ter medical care to patients in rural areas have worked very effectively.

3. As humanitarian projects based on part- nerships with local actors are generally more successful and sustainable, HTM projects should follow this lead.

While involving local populations and au- thorities in project delivery and empower- ing them in that process can be costly due to cultural and language barriers, projects that do so have a higher likeli- hood of succeeding in the long term.

4. A number of important cultural considera- tions, from host and donor populations, should be accounted for.

A number of issues can arise in develop- ment projects due to socio-cultural differ- ences, and this is no different when these

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are health-based. Cultural considerations with regard to medical care differ mark- edly between industrialised and develop- ing countries. These must be accounted for as part of projects administering health services.

5. In order to make such projects success- ful, the medical needs of end users must be prioritised.

While, as mentioned in (4), cultural is- sues arise in the field of medicine, the medical needs of end-users must be pri- oritised. If this is not the case, they may forego the available care, which repre- sents a failure for the endeavour.

6. Every low-hanging fruit should be consid- ered.

Many successful HTM projects use exist- ing or basic technologies to enable the telemedicine link between parties. This should be sought after primarily before developing and importing expensive and

hard-to-manage systems and technolo- gies.

7. To test the validity of primary care HTM, pilot projects need to be developed.

The report highlights the potential of pri- mary care HTM projects to be successful.

However, this cannot be demonstrated without concretely testing them with the use of a prototype. Carrying out a pilot project would effectively test the poten- tial of such projects to succeed on a lar- ger scale.

8. Evaluation is critical for the success of such projects.

While carrying out a pilot project may validate primary care HTM projects in certain settings, accurately measuring its success will indicate whether such a pro- ject should be scaled up and/or replicated across other settings, and whether it is a sound investment in the field of develop- ment. More generally, there is a need for increased feedback in HTM.

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1. Introduction

As McLaren and Ball (1995) wrote in their article for the British Medical Journal: “Re- search is needed on how existing technology can be integrated into health care delivery systems in a way that improves the effec- tiveness and efficiency of those systems”.1 They also stated: “any new communication tool should be rigorously tested against exist- ing technologies such as the telephone”.

1.1 Technological Prowess

Notwithstanding the importance of the tele- phone, other technological instruments are proving to be equally or more cost effective than that ubiquitous tool. With their growing availability, mobile phones, computers and tablets are capable of connecting to the Internet and of supporting its applications.

Through their applications (or apps), these electronic devices hold almost limitless possi- bilities with regards to telemedicine. On the Internet, one may consult extensive medical libraries, access simulated surgeries, learn about medical procedures step by step, ac- cess information on drugs databases, listen to dedicated medical radios, and get the de- tailed procedures of various treatments.

There are also applications being developed where, with a combined use of a mobile phone’s camera and the Internet, the extent of the danger presented by a potential mela- noma can be assessed.2 The range of knowl- edge and capabilities to be transmitted via the Internet to a phone, computer or tablet has barely scratched the surface of the future possibilities presented by these technologies.

The use of real bonfires, to communicate the existence of a contagious disease in a town was at the origin of all this, hard as this may be to remember, at a time of rapid develop- ment in the field of information-systems.

Thus, telemedicine, understood as the deliv- ery of medical care at a distance, is not a by- product of the Internet, or of any new tech-

1 McLaren, Paul and Ball, C. J., “Telemedicine: Lessons Remain Unheeded”, British Medical Journal, Vol. 310, No.

6991 (May 27th 1995): 1390-1391

2 “Top 20 Free iPhone Medical Apps For Health Care Professionals.” 14 December 2010. Web. 30 July 2013

<http://www.imedicalapps.com/2010/12/bes-free-iphone- medical-apps-doctors-health-care-professionals/>

nology for that matter. It has been used throughout history and has grown as much as the very technology it has used (telegraphy, telephone, radio, television and Internet).

Although every technological stride has im- proved the remote care that could be given, technology is not the primary reason for the development of telemedicine; it is merely the tool that has enabled it to prosper. Techno- logical advancement has enabled the con- tinuous fulfilment of medical needs and made it possible to overcome many obstacles to medical care, such as distance and effective transfer of knowledge.

The current technological revolution is chang- ing our approach to medicine and, more than ever, enabling broader healthcare reach through telemedicine. With this in mind, telemedicine has become a well-researched method of administrating medical care both in developing and industrialised countries.

Telemedicine can truly help achieve improved healthcare for all, and particularly for devel- oping countries, where doctors are too often scarce.

1.2 Telemedicine’s Contribu- tion to Society

In 2000, the Member States of the United Nations adopted a resolution aimed at eradi- cating extreme poverty and improving the

“health and welfare of the world’s poorest people within 15 years”.3 From this resolu- tion, eight goals were formulated which are now widely known as the Millennium Devel- opment Goals (MDGs). Health is paramount to these goals. Indeed, six out of eight in- volve health issues.Although telemedicine is not explicitly mentioned in the MDGs, a “dis- appointing” fact for some, the potential of telemedicine can no longer be ignored, as it can certainly be used to help achieve the MDGs.4 For example, existing telemedicine projects deal with secondary care for children in Africa, as well as pregnant women in South

3 “MDG Health and the Millennium Development Goals.”

World Health Organization. 2005. 30 July 2013

<http://www.who.int/hdp/publications/mdg_en.pdf>

4 Merrell, Ronald C., “Medical Diplomacy”, Telemedicine and e-Health, Vol.16, No.6, (July/August 2010): 645-646

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America, helping to achieve MDG Goals 4

“Reducing child mortality” and 5 “Improving maternal health”.

Many telemedicine initiatives and projects have emerged in the past 13 years, providing medical care more easily and effectively at a distance. As mentioned above, recent techno- logical developments have contributed to the advancements of telemedicine. In regions lacking adequate infrastructure, none has done so more than space technology and its applications. Communication satellites are an important facilitator of humanitarian tele- medicine (HTM). With the satellite network’s constant availability, along with its independ- ence from ground environmental conditions, it is a tool that has become indispensable to humanitarian aid. Although the technology involved in satellite networks, reception, and transmission of data is of interest from the point of view of the technologist, in this re- port space is studied solely as a tool that renders telemedicine possible in specific con- texts. Thus, space is analysed in terms of the impact it can have on telemedicine, and therefore on global access to health.

1.3 Telemedicine and Hu- manitarian Telemedicine

With the different initiatives surrounding telemedicine, it is imperative to consider not only the achievements that have been ac- complished, but also what remains to be done in this field. Many telemedicine projects exist, and a number of them are being suc- cessfully executed. However, whether or not all avenues of this field have been explored must be considered. Have all the low-hanging fruit been picked? Can the assistance indus- trialised countries are providing to the devel- oping world in terms of telemedicine be opti- mised?

The aim of this report is to provide an over- view of telemedicine and a more in-depth analysis of HTM, while also analysing the

questions that arise when developing and sustaining such projects, in particular in pri- mary care. Ultimately, this report is designed to address HTM as a method to be acknowl- edged, and pave the way for further discus- sions on the setting up of a prototype in that field in primary care. Due to the capacity of HTM to impact outreach in medical care, it is important to identify the issues to address in order to provide effective assistance.

The first chapter will deal with the concepts, definitions and current use of telemedicine and introduce HTM in developing and indus- trialised countries. The report will then be divided in two sections.

The first section will provide a more in-depth view of successful projects in HTM. It will first look at the use of HTM in different situations, both in scenarios of humanitarian crisis and in permanent situations of hardship. An over- view of different civilian and military projects will be given in both primary and secondary care. It will then lay out the potential these projects have for cooperation and develop- ment. Both the medical aid provided from industrialised (national and international ini- tiatives) and developing countries (the Indian experience at home and abroad) will be stud- ied.

The second section will be centred on primary care in HTM and the possible way forward in this area. First, the lessons learned from past HTM projects will be examined. The lessons learned, the analysis of what works for de- veloping countries, and the challenges that may occur will be studied. Second, a closer look will be given to opportunities and chal- lenges that may arise when developing and implementing HTM primary care projects.

Despite the numerous projects that can be found in secondary care, there still remains a gap in the remote delivery of primary care.

It will then lay out the initial steps in estab- lishing a prototype to test the theoretical framework of primary care HTM.

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»

2. From Telemedicine to Humanitarian Telemedicine

As presented in the introduction, the technol- ogy behind the advances in remote medical care, although of great value, is only as im- portant as the possibilities it generates for the continued advancement of telemedicine.

As Coiera (1995) stated: “Any attempt to use information technology will fail dramatically when the motivation is the application of technology for its own sake rather than the solution of clinical problems”.5

There is, however, a need to acknowledge technological developments, as without them, we would still refer to remote medical care as just that. Telemedicine, in the last decades, has become much more than the creation of a bonfire to ward off people, it thrives on newly developed technologies. The potential types of transmission presented by new tech- nologies and their applications need to be laid out to fully understand the reach that tele- medicine has come to have. The involvement of the international community and regional institutions in telemedicine, as well as the specific national applications of telemedicine, are important inasmuch as they help set the basis for HTM.

2.1 What Is Telemedicine?

2.1.1 Defining Telemedicine

Although telemedicine etymologically trans- lates to medicine at a distance, many defini- tions of the term can be found ranging from the broad to the specific. One of the broadest definitions of telemedicine comes from Woot- ton, who defines telemedicine as “an um- brella term that encompasses any medical activity involving an element of distance”.6 Craig and Patterson elaborate on this defini- tion of telemedicine: “the delivery of health care and the exchange of health-care infor- mation across distances […], it encompasses the whole range of medical activities includ- ing diagnosis, treatment and prevention of disease, continuing education of health-care providers and consumers, and research and

5 Coiera, Enrico “Medical informatics.” British Medical Journal, Vol. 310, No. 6991 (May 27, 1995): 1381-1387.

6 Wootton, Richard “Telemedicine.” British Medical Journal, Vol. 323, Clinical Review (September 8, 2001): 557-560

evaluation”.7 Furthering the idea of inclusion in the definition, the United Nations (UN) has defined telemedicine as:

“the delivery of health care services, where distance is a critical factor, by all health care professionals using informa- tion and communication technologies for the exchange of valid information for di- agnosis, treatment and prevention of dis- ease and injuries, research and evalua- tion, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”.8

Whereas these definitions are very inclusive in their interpretation of telemedicine, other authors, such as Wyatt and Liu, have speci- fied telemedicine to be: “the use of any elec- tronic medium to mediate or augment clinical consultations. Telemedicine can be simulta- neous (for example, telephone, videoconfer- ence) or store and forward (for example, an email with an attached image)”.9 In the latter definition, the types of information technol- ogy are included. Indeed, unlike the first set of definitions, which lists the current applica- tions that can be found in telemedicine, the definition proposed by Wyatt and Liu consid- ers the structural aspect of telemedicine.

Telemedicine implies distance, and the infor- mation transmitted over that distance can either be synchronous or asynchronous.

When trying to define a concept such as telemedicine, a wide range of definitions is thus available. Far from wanting to burden the already extensive list of definitions, for the purpose of this report telemedicine will be defined as the delivery at a distance of pri- mary and/or secondary care between a medi- cal professional and a patient or between two or more medical professionals by way of syn- chronous or asynchronous transmission and communication. Therefore, medical tele- education does not fall under this definition.

7 Craig, John and Patterson, Victor, “Introduction to the practice of telemedicine”, Introduction to Telemedicine, Eds. Richard Wootton, John Craig and Victor Patterson, The Royal Society of Medicine Press Limited (2011): 3-4

8 “Telemedicine Opportunities and Developments in Mem- ber States 2010”. Global Observatory for eHealth series.

Vol. 2. World Health Organization, 30 July 2013

9 Wyatt, J.C. and Liu, J. T. L. “Basic Concepts in Medical Informatics.” Journal of Epidemiology and Community Health, Vol. 56, No. 11 (November 2002): 808-812

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2.1.2 Terms and Terminology

In order to understand telemedicine beyond its definition and within its wider context, a few terms need to be addressed. Indeed, not only has telemedicine come to the forefront of health agendas around the world, it has

been increasingly categorised, and a number of terms have been used to define it. For example, telehealth and telemedicine are often not properly distinguished. Figure 1 provides an overview of the most commonly used terms and concepts with regards to both categories of health-related activities.

Figure 1: Telehealth and telemedicine applications

Telemedicine is part of a wider concept re- ferred to as telehealth, which encompasses all health related teleservices.10 On a national level it may also refer to “public health ser- vices delivered at a distance, to people who are not necessarily unwell, but who wish to

10 Cluzel, Jean, Alajouanine, Guislaine and Grebot, Elisa- beth, Groupe d’études de l’Académie des sciences mora- les et politiques, “Les nouvelles technologies de

l’information et de la communication au service de la santé en Afrique”, Presses Universitaires de France (2003): p.14

remain well and independent”.11 Telehealth is therefore an overarching term and telemedi- cine falls under its umbrella.12

Telehealth is, however, not to be confused with e-health. E-health refers explicitly to the

11 Craig, John and Patterson, Victor, “Introduction to the practice of telemedicine”, Introduction to Telemedicine, Eds. Richard Wootton, John Craig and Victor Patterson, The Royal Society of Medicine Press Limited (2011):3-4

12 “What is telemedicine.” ICUcare LLC. Web. 30 July 2013.

<http://www.icucare.com/PageFiles/Telemedicine.pdf>

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use of the Internet as part of the medical exercise. It includes all the concepts that fall under telehealth, but is exclusive, as it only considers the Internet as a medium. Although e-health might be considered as more rele- vant in today’s world, due to the ubiquitous- ness of the Internet, other types of telecare are also essential, due to the variety of com- munication channels available in different settings.13,14

2.1.3 Applications of Telemedicine

Telemedicine encompasses a number of ap- plications. Figure 1 represents the most common ones, which include tele- care, diag- nostics, mentoring, radiology, surgery, con- sultation, and monitoring.

Teleradiology or tele-imagery is “the elec- tronic transmission of [ultrasounds or] radio- logical images, such as x-rays, CTs, and MRIs, for the purposes of interpretation and/or consultation. Digital images are transmitted over a distance using standard telephone lines, satellite connections, or local area networks (LANs)”.15 The digitalisation of images, which are made available directly to the doctor, has important advantages. In- deed, there are increased interactions be- tween doctors and patients who are in re- mote locations. Additionally, there is no greater risk of imagery misinterpretation.16 Telediagnostics, like all other applications, can be either synchronous or asynchronous.

It can also be done between a medical pro- fessional and a patient or between two or more medical professionals. Telediagnostics has proven to be a time efficient and invalu- able tool for telehealth. For example, when a hospital possesses radiological equipment but not medical specialists, rather than system- atically sending high-risk patients to a nearby hospital, an image can be taken and sent to a specialist, who then deliberates on the need to move the patient or not.17 This is closely linked to the concept of teleconsultation, since it is a clinical consultation between a

13 Wyatt, J. C. and Liu, J.T.L, “Concepts in Medical Infor- matics”. Journal of Epidemiology and Community Health.

Vol. 56, No. 11 (November 2002): 808-812

14 Cluzel, Jean, Alajouanine, Guislaine and Grebot, Elisa- beth, Groupe d’études de l’Académie des sciences mora- les et politiques, “Les nouvelles technologies de

l’information et de la communication au service de la santé en Afrique”, Presses Universitaires de France (2003): p.14

15 “What is telemedicine.” ICUcare LLC. Web. 30 July 2013.

<http://www.icucare.com/PageFiles/Telemedicine.pdf>

16 Cluzel, Jean, Alajouanine, Guislaine and Grebot, Elisa- beth, Groupe d’études de l’Académie des sciences mora- les et politiques, “Les nouvelles technologies de

l’information et de la communication au service de la santé en Afrique”, Presses Universitaires de France (2003): p.17

17 Ibid. p. 18

patient and a medical professional, or two medical professionals.18 However, in the case of teleconsultation, one is mainly asking for a second opinion or advice. Within the relation- ships that may be established between two medical professionals, Telementoring is yet another application of telemedicine. Telemen- toring uses “audio, video and other telecom- munications and electronic information proc- essing technologies to provide individual guidance or direction”.19 Unlike teleconsulta- tion, telementoring implies a longer relation- ship between the two medical professionals and a notion of teaching and educating, rather than the offering of a medical opinion on a single case.

Telesurgery is an application of telemedicine that may seem far-fetched even though doc- tors have been using robotic technologies inside their operating rooms for decades.

They are now also capable of performing cross-continental surgeries. A recent break- through in telesurgery featured a doctor in the United States (US) performing surgery on a patient in France, by “remotely operating a surgical robot arm”.20 The success of the operation proved that telesurgery has great potential.

The last two applications are, in turn, ori- ented towards patient care and monitoring.

Whereas telemonitoring focuses on monitor- ing the health status of a patient following a specific event, telecare is a more rounded provision of medical attention to a pa- tient.21,22 An example of telemonitoring oc- curs when medical professionals remotely follow individuals with diabetes who need to take their medicine. On the other hand, an example of telecare is when an elderly person in a home receives general care at a dis- tance.

As previously noted, telemedicine is only possible when the appropriate technology is available. All of these telemedicine applica- tions have been made possible at one time or another by space-based capabilities. The progress that has been achieved in the re-

18 Coiera, Enrico “Medical informatics.” British Medical Journal, Vol. 310, No. 6991 (May 27, 1995): 1381-1387.

19 “What is telemedicine.” ICUcare LLC. Web. 30 July 2013.

<http://www.icucare.com/PageFiles/Telemedicine.pdf>

20 „Doctors claim world first in telesurgery”. BBC News.

Wednesday, 19 September 2001. Web. 30 July 2013

<http://news.bbc.co.uk/2/hi/science/nature/1552211.stm>

21 “What is telemedicine.” ICUcare LLC. Web. 30 July 2013.

<http://www.icucare.com/PageFiles/Telemedicine.pdf>

22 Craig, John and Patterson, Victor, “Introduction to the practice of telemedicine”, Introduction to Telemedicine, Eds. Richard Wootton, John Craig and Victor Patterson, The Royal Society of Medicine Press Limited (2011):3-4

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Figure 2: The role of space in telemedicine and telehealth (English translation from CNES.fr 2008)

mote delivery of medical care can be traced back to telecommunication, Earth observation and global positioning satellites (see figure 2).23

Telecommunication satellites can enable the connection between remote mobile units, isolated proximity sites, and expert sites. In other cases, such as telemonitoring or tele- care, satellite connectivity not only allows for the remote monitoring of patients, but also for their positioning. Therefore, if a patient located in a remote area is in need of imme- diate assistance, an emergency relief unit can be dispatched to their location. These are but a few examples of the opportunities created by space-based infrastructure.

2.2 Widespread Use of Tele- medicine in Industrialised Countries

With the explosion of telemedicine and its applications has come an increase in its im- plementation within industrialised countries and the international community. Beyond the immediate benefits of telemedicine for deliv-

23 Figure 2 source: “The first operational networks monitor- ing re-emergent diseases”. CNES. Web. 16 January 2014

< http://www.cnes.fr/web/CNES-en/5078-the-first- operational-networks-monitoring-re-emergent- diseases.php>

ering healthcare, it has now not only become a tool for diplomacy and development but has also gained momentum in political agendas around the globe.24 International organisa- tions such as the World Health Organization (WHO) and the UN have taken a keen inter- est in the matter. Other regional actors have also taken an interest in this domain. For example, the European Union (EU) has in- cluded the topic in its strategy for EU growth, represented by its Europe 2020 strategy.

Telemedicine is an integral part of national health care policies and has in recent years grown and benefitted greatly from experi- ence.

2.2.1 International Community International Organisations

Since 2005, telemedicine has been a subject of growing interest for the international community and its health agenda. Following its Global eHealth Survey, the WHO, the pri- mary international organisation on matters of health, affirmed the need to include eHealth in its strategy and urged others to do the same. Indeed, in its Ninth plenary meeting, on 25 May 2005, the WHO noted “the poten- tial impact that advances in information and communication technologies could have on health-care delivery, public health, research

24 Merrell, Ronald C., “Medical Diplomacy”, Telemedicine and e-Health, Vol.16, No.6, (July/August 2010): 645-646

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and health-related activities for the benefit of both low- and high-income countries”.25 It also urged Member States to “consider draw- ing up a long-term strategic plan for develop- ing and implementing eHealth services in the various areas of the health sector, including health administration, which would include an appropriate legal framework and infrastruc- ture and encourage public and private part- nerships”. Additionally, it requested its Direc- tor-General “to promote international, mul- tisectoral collaboration with a view to improv- ing compatibility of administrative and technical solutions and ethical guidelines in the area of eHealth”.26 With this renewed political will, the year 2005 represented a milestone in the promotion of telemedicine and eHealth, not only for the WHO but also for many other organisations such as the UN and the EU.

The UN has long promoted the practical use of space, which includes telemedicine. During the 2005 General Assembly, the Fourth Committee (focused on special political ques- tions and decolonisation) dedicated its ses- sion to the potential contribution of space technologies to the MDGs.27 The idea that technology can provide assistance in the achievement of the MDGs was reiterated in the 2011 Report of the Reflection Group on the delays that had occurred in their realisa- tion. The importance of Information and Communication Technologies (ICTs) was highlighted, and among the many positive applications that could be utilised were eHealth and telemedicine.

Thus, the WHO and the UN have expressed a need for eHealth, both as a general direction to be undertaken by other organisations and states, and for the achievement of the MDGs.They are also both partners of the In- ternational Society for Telemedicine and eHealth (ISfTeH), whose mission is to “facili- tate the international dissemination of knowl- edge and experience in Telemedicine and eHealth and to provide access to recognised

25 The World Bank divides state economies according to Gross National Income per capita. The economies are then classified into income groups, where: low income, $1 035 or less; lower middle income, $1 036 - $4 085; upper middle income, $4 086 - $12 615; and high income, $12 616 or more. Source “Country Classification.” Worldbank.

Web.30 July 2013

<http://data.worldbank.org/about/country-classifications>

26 World Health Organization. Resolutions and Decisions on its Fifty-Eighth World Health Assembly, Held in Geneva from 16 to 25 May 2005. WHO Doc. WHA58/2005/REC/1

27 “Quatrième Commission: Les Technologies Spatiales Peuvent Contribuer Aux Objectifs Du Millénaire Pour Le Développement.” United Nations General Assembly. 17 October 2005.

CPSD/321. Web. 30 July 2013

<http://www.un.org/News/fr-

press/docs/2005/CPSD321.doc.htm>

experts in the field worldwide”.28 The interna- tional community has rallied together on the issue of eHealth and telemedicine and this has also impacted regional strategies, namely the EU’s Europe 2020 strategy for growth.

European Union

In 2004 the European Commission (EC), with the aim of developing ICTs in the Health sec- tor, adopted an action plan that resulted in increased national eHealth strategies.29 It was not until 2008, however, that the EC renewed its firm intent to include eHealth in its policy and strategy. In 2008, eHealth be- came a part of the Lead Market initiative for innovation, which was followed up by the launch of a survey on eHealth. In April 2008, the EC published the results of the “Bench- marking ICT use among General Practitioners in Europe” survey, which concluded that European doctors were widely practising eHealth. Following these results, the EC sent a communication to the other EU institutions promoting the development of eHealth.30 In 2010, the EC proposed a new political strategy to achieve growth that is smart, sustainable and inclusive. In order to achieve this, it presented five targets to be achieved by 2020, hence “Europe 2020”.31 Following the setting of these targets, a programme composed of seven flagship initiatives was set up. The first of these was the Digital Agenda for Europe, which aimed “to help Europe's citizens and businesses to get the most out of digital technologies”.32 Within this Digital Agenda for Europe, seven actions have been taken, one of which is to use “In- formation and Communication Technologies - enabled benefits for EU society”. Four main

28 “Mission Statement IsfTeH.” ISfTeH. Web. 30 July 2013

<http://www.isfteh.org/about/about_the_isfteh>

29 “Survey takes pulse of eHealth in Europe and prescribes wider ICT use among doctors.” European Commission.

IP/08/641 Web. 25 April 2008

<www.europa.eu/rapid/press-release_IP-08- 641_en.htm?locale=en>

30 “Communication from the commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions on telemedicine for the benefit of patients, healthcare systems and society. European Commission. COM(2008)689 final 4 November 2008.

31 Commission of the European Communities. Communi- cation from the Commission to the European Parliament, the Council, the European Economic and Social Commit- tee and the Committee of the Regions, on telemedicine for the benefit of patients, healthcare systems and society.

COM (2008)689 final of 4 November 2008. Brussels:

European Union.

32 European Commission. Communication from the Com- mission to the European Parliament, the Council, the European Economic and Social Committee and the Com- mittee of the Regions, a Digital Agenda for Europe. COM (2010) 245 final/2 of 26 August 2010. Brussels: European Union.

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areas were identified to benefit from ICT, including healthcare.33

With regard to space and health more specifi- cally, although the EU has included European citizens in its space strategy, it has not ad- dressed the topic of health for developing countries. Neither the European Space Policy

“green and white paper series” (2003), nor the 2011 EC communication "Towards a space strategy for the EU that benefits its citizens" mentions the topic. Although the 2011 communication expresses the need for Earth observation data for “transport safety, cartography, the management of water and rivers, food resources and raw materials, biodiversity, soil use, deforestation and com- bating desertification”, it does not reference how space technology can be relevant in a health context outside the EU.34

The importance that the EU has decided to give to eHealth is representative of the global interest in the topic and the need to deal with this issue. Not only are international and regional organisations recognizing the need to include eHealth and telemedicine in their health agendas and strategies, they are also, through international associations and tar- geted promotion activities, actively promoting it worldwide.

2.2.2 National Initiatives

With the growing international concern for the inclusion of eHealth and telemedicine in policies and practices, it is important to ana- lyse some direct results of telemedicine appli- cations in industrialised countries.

Successes of Telemedicine

Many projects featuring eHealth and tele- medicine applications have been imple- mented in recent years. As early as 1997, the Veterans Health Administration (VHA),

“America’s largest integrated health care system with over 1,700 sites of care, serving 8.3 million Veterans each year”, was “sys- tematically delivering clinical services via telemedicine”.35,36 The VHA is now running a range of telemedicine services, including the

33 Ibid.

34 Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions towards a space strategy for the European Union that benefits its citizens. European Commission. COM (2011) 152 Final of 4 March 2011.

35 “Veteran Health Administration.” US Department of Veterans Affairs. Web. 27 March 2013

<http://www.va.gov/health/default.asp>

36 Crigger, Bette-Jane. “e-Medicine: Policy to Shape the Future of Health Care.” The Hasting Center Report. Vol.

36. No.1 (January-February 2006): 12-13

tele-anticoagulation program, tele-women’s health, tele-palliative care, and the tele- amputee clinic, which provides assistance for veterans who have had limbs amputated.37 Although many early breakthroughs in the field of telemedicine were accomplished in the military, nowadays, many programmes also flourish in the civilian sector.

The essence of telemedicine is to provide care at a distance and therefore reach those living in secluded areas.38 Telemedicine has the potential to improve and save lives in areas that would otherwise be unserviced.

Among the many published studies on the subject, the nationwide British Whole System Demonstrator Project is the “largest random- ized trial of telehealth in the world”.39 The trial centred around two groups of patients, those who received telehealth and those who received usual care. It was shown that there were fewer deaths in the group that received telehealth. Another study conducted in the US focused on improving diabetes self-care with a Personal Digital Assistant (PDA). It showed that the patients that kept their PDA at all times and completed the programme improved their diabetic situation.40

In addition to reducing health inequalities and improving access to medical care, telemedi- cine improves efficiency and, in some cases, reduces costs. For example, unnecessary journeys to the hospital as well as between hospitals can be drastically reduced with the effective use of telemedicine.41 The British Whole Demonstrator Systems Project found that there were 20 percent fewer emergency hospital admissions among patients receiving telehealth.42 Electronic referrals to specialists and hospitals have also been found to be cheaper for both patients and doctors. The costs for a patient to drive to a medical spe- cialist, or for a doctor to visit a home, can

37 “Telehealth: Care and Convenience for Veterans.” US Department of Veterans Affairs. Web. 27 March 2013

<http://www.va.gov/health/NewsFeatures/2013/March/Tele health-Care-and-Convenience-for-Veterans.asp>

38 Wootton, Richard. “Telemedicine” (2001)

39 “The Impact of Telehealth and Telecare: the Whole System Demonstrator Project” nuffieldtrust. Web. 30 July 2013 < http://www.nuffieldtrust.org.uk/our-

work/projects/impact-telehealth-and-telecare-evaluation- whole-system-demonstrator-project>

40 Forjuoh, Samuel N. et al. “Improving Diabtes Self-Care with a PDA in Ambulatory Care.” Telemedicine and e- Health. Vol. 14. No. 3 (April 2008): 273-280

41 Wootton, Richard “Telemedicine.” British Medical Jour- nal, Vol. 323, Clinical Review (September 8, 2001): 557- 560

42 “The Impact of Telehealth and Telecare: the Whole System Demonstrator Project” nuffieldtrust. Web. 30 July 2013 < http://www.nuffieldtrust.org.uk/our-

work/projects/impact-telehealth-and-telecare-evaluation- whole-system-demonstrator-project>

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often be eliminated using teleconsultations.43 Although many initiatives exist, too few coun- tries are equipped with these capabilities and the will to fully incorporate telemedicine into their national health systems.

Implementation Considerations

As Bashshur and Armstrong posited, as early as 1976, telemedicine features include “a heavy reliance on telecommunication tech- nology”, “the development of organizational forms uniquely suitable for the remote deliv- ery of medical services”, and “an expanded clinical role for the medical provider without an M.D. degree”.44 Only a few countries are capable of strongly engaging in it. For exam- ple, within Europe, Denmark, the Netherlands and Norway boast the highest levels of tele- medicine (use of email, e-prescriptions, telemonitoring, etc.).45,46 The reason for tele- medicine’s rather modest practical uptake is that other factors must be considered in addi- tion to the “e-readiness” that states must possess in order to engage in telemedicine.

Telemedicine may indeed not be applicable in all medical cases, and resistance to it can arise from both patients and doctors. There is much to be said about the cultural difficulties involved in establishing a relationship be- tween a doctor and a remote patient. Indeed, in some studies, medical professionals have been found to be resistant to the idea of hav- ing reduced face time with their patients.

They believe that telemedicine “depersonal- izes the relationship and sabotages the trust”

that doctors have with their patients.47,48 Still, telemedicine presents numerous advan- tages for both healthcare providers and bene- ficiaries. States and institutions must, how- ever, acknowledge the difficulties that come with this new mode of health care admini- stration. Not only should the changing rela- tionship between the parties be acknowl- edged and addressed, but so must the pa- tient needs with regards to their conditions, the changing health infrastructure and the

43 Wootton, Richard “Telemedicine.” British Medical Jour- nal, Vol. 323, Clinical Review (September 8, 2001): 557- 560

44 Bashshur, Rashid A., and Patricia A, Armstrong. “Tele- medicine: A New Mode for the Delivery of Health Care.”

Inquiry. Vol.13. No.3 (September 1976): 233-244

45 European Commission. Press Release. “Survey takes pulse of e-Health in Europe and Prescribes Wider ICT Use among Doctors.” IP/08/641 on 25 April 2008. Brussels:

European Union.

46 “Services” NST Norwegian Centre for Integrated Care and Telemedicine. Web. 25 September 2013 <

http://www.telemed.no/services.5108575-258951.html>

47 Brindle, David. “Telehealth ‘not Effective’ for People with Long-Term Conditions, Study Finds” The Guardian 27 February 2013. Web. 30 July 2013.

48 Chen, Pauline W. “Are Doctors Ready for Virtual Visits?”

The New York Times 7 January 2010. Web. 30 July 2013.

interactions between these factors. The aforementioned issues are even more rele- vant when considering HTM, where patients are often less familiar with advanced medical technologies, and where local conditions are less conducive to medical care.

2.3 Defining Humanitarian Telemedicine

The Oxford dictionary defines the adjective

“humanitarian” as a “concern or desire to promote human welfare”.49 The term HTM, however, has a more specific meaning: it is understood as the provision of telemedicine (primary and/or secondary) to developing countries in times of immediate and/or per- manent medical need with the aim of improv- ing personal health.

The medical aid in question may be provided by medical entities from either industrialised and developing countries or a combination of both. Furthermore, in this definition, an en- tity refers to either a governmental or non- governmental national or international or- ganisation, or a private sector firm. It should be noted that the medical aid may be pro- vided to, and from, more than one entity at a time; it may arise from a partnership be- tween private and non-governmental organi- sations (NGOs), or between hospitals and/or local NGOs. Figure 3 depicts the relationship between the actors involved.

As highlighted earlier in this section, tele- medicine includes a wide range of medical initiatives taking place at a distance. The same can be said of HTM. Both in cases of humanitarian crises and in cases of enduring hardship, HTM can play a crucial role in in- creasing access to medical services. HTM’s role is to deliver primary or secondary care to those who are in need and who are located in underserved regions. It constitutes an inte- gral part of the effort to help improve world- wide access to health care.

Just as surgery and orthopaedics are stand- alone areas of medicine, so is HTM, even if it encompasses a variety of medical disciplines.

With so many regions in the world in a dire need of medical care, HTM has brought forth the possibility not only to overcome distances

49 “Humanitarian.” Oxford Dictionaries. 27 March 2013.

<http://oxforddictionaries.com/definition/english/humanitari an?q=humanitarian>

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Figure 3: HTM representation

and provide medical care to the most remote regions of the world, but also to improve health care in general. A lack of access to medical professionals constitutes a challenge for patients, and medical institutions them-

selves. HTM possesses its own limitations, structural needs and characteristics, which need to be identified and analysed by those wishing to develop and implement HTM pro- jects.

Primary care Secondary care

Partnership opportunities

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Part 1. Successful Humanitarian Telemedicine Projects

3. Popular Uses of Humanitarian Telemedicine

As shown in the first section, HTM concerns itself with the delivery of healthcare in coun- tries that are in a permanent situation of hardship or in humanitarian crises. These two types of situations require distinct HTM measures. Whereas countries facing humani- tarian crises require urgent, immediate help, those facing more systemic hardship, al- though equally in need of immediate action, are also in need of long-term assistance. The following section distinguishes between the two types of situations.

3.1 Permanent Situation of Hardship

Many countries are in a dire situation when it comes to health and their population’s access to it. There are severe health care distribu- tion inequalities, not only between industrial- ised and developing countries, but also within developing countries. Whereas cities gener- ally hold the few available health profession- als and access facilities, rural areas face se- vere shortages.50

In HTM, as elsewhere, healthcare can be either primary or secondary in nature.

Whereas primary care consists of medical treatment provided by medical generalists directly to patients, secondary care refers to a treatment dispensed by specialised doc- tors.51 In terms of telemedicine, both primary and secondary in nature, the most commonly used applications are telediagnostics and teleconsultations.

50 “Squeezing out the Doctor”. The Economist 2 June 2012: 25-27. Print.

51 “Primary Care. Cambridge Dictionary. Web. 16 April 2013

<http://dictionary.cambridge.org/dictionary/british/primary- care?q=primary+care> and “secondary care.” Cambridge Dictionary. Web. 16 April 2013.<http://medical-

dictionary.thefreedictionary.com/secondary+care>

Teleconsultation aims to “move expertise, not people”.52 While there is a shortage of doc- tors in certain developing countries, medical specialists represent an even rarer “commod- ity”. It is therefore crucial to connect them with each other and with primary care medi- cal specialists. The Medical Missions for Chil- dren (MMC) and the Réseau en Afrique Fran- cophone pour la Télémedicine (RAFT) projects are examples of the many projects enabling this connection. The RAFT project offers re- mote assistance with diagnostics, provides second medical opinions, and assists with the evaluation, decision, and planning of medical evacuations and transfer of patients. Through asynchronous communication, medical pro- fessionals are able to reach each other and ask for medical opinions in specialised areas such as radiology, dermatology, surgical fol- low-ups, and infectious diseases.53 In addi- tion to enabling the connection between doc- tors or specialists who need assistance on a difficult case, the benefits that arise with a more permanent connection are not to be dismissed. Thus, MMC’s Telemedicine Out- reach Program provides mentoring in addition to specialist medical paediatric advice. The same is true for RAFT. Help can now be pro- vided in the monitoring of treatment, the supervision of specialised services, and ad- vances in diagnostic tools. Teleconsultations have proven their benefit, which is high- lighted by the number of countries that par- ticipate in such projects, 108 in the case of MMC, and in the number of requests for tele- expertise that are made, 800 per year in the case of RAFT.54

52 Geissbuhler, Antoine. “Telemedicine for Development and Humanitarian Purposes.” European Space Policy Institute, HTM. 14 June 2012 in Vienna

53 Ibid. and “The RAFT network A Telemedicine Network in Africa to Support Healthcare Professionals where they are Most Needed” RAFT Web. 30 July 2013

<http://raft.hcuge.ch/10-04-

14%20RAFT%20detailed%20description.pdf>

54 Geissbuhler, Antoine. “Telemedicine for Development and Humanitarian Purposes.” European Space Policy Institute, HTM. 14 June 2012 in Vienna and Riehl, John.

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Whereas teleconsultations are increasing, another application of telemedicine has shown to be successful: telediagnostics. It truly epitomises the idea of “moving exper- tise, not people”. While teleconsultations and telementoring mostly occur between two medical professionals, telediagnostics gener- ally involve a direct link, through video for example, between a medical professional and a patient, in which the medical professional could be located on another continent. There is often, however, a nurse or another medical professional present with the patient, who helps transmit, translate, and/or apply the decisions made by the off-site medical pro- fessional. In existing projects developed in the area of telediagnostics, the local point of contact can either be fixed or mobile. There- fore, in order to truly move expertise in the area of diagnostics, a project can have a mo- bile point of contact, such as the telemedicine

“suitcase” developed by the French Space Agency CNES in French Guyana.55 The aim of this initiative is to offer a primary diagnostic to identify whether it is necessary to transfer a patient. With a computer, a satellite phone, a microscope, an electrocardiogram, and a digital camera, the information is gathered in the field and sent (via satellite connection), to the hospital in Cayenne. The decision to transfer the patient is then taken directly by a medical professional located at the hospi- tal.56 Using technology originally developed for the primary care of astronauts, CNES has broadened the reach of primary care services to some of the most secluded areas of French Guyana.

Teleconsultations are among the most popu- lar telemedicine applications used for HTM.

Due to the ease with which they are estab- lished, their presence can be easily observed in the vast majority of the projects where they are used. For example, in Operation Village Heath (OVH), over 800 patients have received care. The operation was originally set up by Harvard-affiliated physicians to support Cambodian health workers. With a fixed point-of-care, clinical data such as medical histories, physical exams, and lab and digital images are transmitted to Boston, and diagnoses are then sent back to Phnom Penh via email within hours.57 The main ob-

“Telemedicine in Action: the Example of Medical Missions for Children.” European Space Policy Institute, HTM. 14 June 2012 in Vienna.

55 “Téléconsultation, un service d’urgence dans une va- lise.” CNES. Web. 30 July 2013.

<http://www.cnes.fr/web/CNES-fr/6352-teleconsultation- un-service-durgence-dans-une-valise.php>

56 Ibid.

57 “Operation Village Health” Centre for Connected Health Web. 30 July 2013 < http://www.connected-

health.org/programs/remote-consults--virtual-visits/center-

jective of the OVH programme is diagnosis of patients at a distance. These projects have not only saved lives but have also improved medical awareness among local populations, and helped de-isolate medical profession- als.58 In the Cambodian village where OVH operates, the waiting time to receive medical attention has been decreased from three years to six months. Additionally, in areas where transport constitutes a financial bur- den, the efficiency of such systems enables substantial savings from cases where patients do not require to be transported but might have otherwise.

3.2 Situations of Humanitar- ian Crisis

When developing countries are struck by a disaster, they witness a great need for medi- cal aid, as their medical structures can often find their situation unmanageable. Therefore, many HTM projects can be found in such situations. Indeed, a majority of the aid dis- tributed via telemedicine is intended to rem- edy situations of crisis.

The UN has defined disaster as a “serious disruption of the functioning of society, caus- ing widespread human, material or environ- mental losses which exceed the ability of the affected people to cope using its own re- sources”, or in the case of developing coun- tries, further exceed their ability to cope.59 Disasters may be natural or man-made. On the one hand, natural disasters are charac- terised as being unintentional and are cate- gorised by the Centre for Research on the Epidemiology of Disasters (CRED) into six categories: “geophysical [e.g.: earthquakes or volcanoes], meteorological [e.g.: hurri- canes, cyclones and tornadoes], hydrological [e.g.: floods], climatological [e.g.: extreme temperatures, droughts or wildfires], biologi- cal [epidemic or infestations], and extra- terrestrial [e.g.: meteorites]”.60 On the other hand, man-made disasters may be uninten- tional (e.g.: chemical and radiation release, structure collapses, or sinking boats…) or intentional (e.g.: a result of terrorism or

for-connected-health-initiatives/operation-village- health.aspx>

58 Ibid.

59 World Health Organization. “Coping with Emergencies:

WHO Strategies and Approaches to Humanitarian Action.”

Geneva. 1995.

60 Judkins, Daniel G, Rifat Latifi, and George J Hadeed,.

“Trauma and Disasters as a Worlwide Problem: An Over- view.” Telemedicine for Trauma Emergencies and Disaster Management. Ed. Rifat Latifi. Norwood: ARTECH HOUSE, 2011. 23-35. Print.

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